Transtibial amputees from the Vietnam War. Twenty-eight-year follow-up.

BACKGROUND: The long-term functional outcome following lower-extremity amputation is not well documented. I ascertained the functional outcome and health status of patients who had sustained a unilateral transtibial amputation as a result of a battlefield injury. METHODS: The records of 123 patients who had been treated at Valley Forge Army General Hospital during the Vietnam War for a diagnosis of isolated transtibial amputation due to a battlefield injury were reviewed. Group 1 had an isolated transtibial amputation, and Group 2 had at least one other major injury (another major long-bone fracture of the lower extremity, burns covering >20% of the body surface area, or a chest, abdominal, face, or head wound) in addition to the transtibial amputation. Seventy-two (59%) of the patients were enrolled in the study: twenty-eight were in Group 1 and forty-four, in Group 2. Data were collected about employment status, marital status, whether the patient had children, and use of psychological support services. The Short Form-36 (SF-36) health survey was used to compare Group 1 and Group 2, individually and combined, with age and gender-matched controls. Scaled scores for the two groups (control and amputation) were compared with use of the Student t test (two-tailed). RESULTS: Tripping a land mine or booby trap caused 65% of the injuries. The average age at the time of follow-up was forty-eight years. The average time to follow-up was twenty-eight years. Only the prevalence of the use of psychological support services differed significantly between Groups 1 and 2 (21% compared with 50%; p = 0.015). The results of the SF-36 health survey for Groups 1 and 2 were 81.6 and 58.2, respectively, for physical function, 82.7 and 33.1 for role physical, 81.4 and 50.9 for bodily pain, 74.1 and 58.7 for general health, 67.1 and 51.5 for vitality, 89.1 and 70.4 for social function, 88.1 and 56.0 for role emotional, and 79.5 and 64.0 for mental health. The average scaled scores for Group 1 were similar to those for the age and gender-matched controls, but the scores for Group 2 were significantly lower (p < or = 0.001) than those for the age and gender-matched controls in all categories. CONCLUSIONS: Group-1 patients led relatively normal lives after sustaining a transtibial amputation in battle. The addition of another major injury (Group 2) appears to have significant long-term consequences with regard to SF-36 scores and the need for psychological care.

Long-term follow-up study of bilateral above-the-knee amputees from the Vietnam War.

BACKGROUND: Because caring for patients who have combat-related amputations is a discontinuous practice, military surgeons must relearn treatment techniques during each conflict. METHODS: The purpose of the present long-term study (average duration of follow-up, 27.5 years) was to document the status of patients who had sustained a bilateral above-the-knee amputation in Vietnam and had been managed by the only separate amputee service in the United States Army. A review of the records of 484 battle amputees identified thirty individuals (6 percent) who had a bilateral above-the-knee amputation. Twenty-six (87 percent) of the thirty patients had been injured by a land mine or a booby trap. Fifty-three (88 percent) of the sixty limbs were amputated because of trauma, and the other seven (12 percent) were amputated secondarily because of infection. Data regarding education, employment, marriage and family life, prosthetic use, and psychological care were collected by mail or telephone for twenty-three (85 percent) of the twenty-seven surviving patients. Respondents also completed the Short Form-36 (SF-36) Health Survey. RESULTS: At the time of the study, five (22 percent) of the twenty-three respondents used prostheses for walking; the devices were used for an average of 7.7 hours per day. Sixteen respondents (70 percent) were or had been employed outside of the home since the time of discharge. The physical functioning score on the SF-36 questionnaire was significantly lower for the study group than it was for a group of age and gender-matched controls (p < 0.001; Student two-tailed t test). With the numbers available, no significant differences could be detected between the groups with regard to physical role functioning (p = 0.377), bodily pain (p = 0.603), general health (p = 0.407), vitality (p = 0.949), social functioning (p = 0.460), emotional role functioning (p = 0.029), or mental health (p = 0.102). CONCLUSIONS: The patients in the present study have led relatively normal, productive lives within the context of their physical limitations.

Effect of refractive surgery experience on outcomes after photorefractive keratectomy.

BACKGROUND: Excimer laser photorefractive keratectomy is effective in the treatment of myopia. It is unclear whether the refractive and ocular surgical experience of the surgeon influences outcome. METHODS: Photorefractive keratectomy was performed on 131 consecutive myopic eyes by one experienced refractive surgeon and on 428 consecutive myopic eyes by six other less experienced surgeons. Outcome data were compared between groups. RESULTS: The mean preoperative spherical equivalent was -5.76 +/- 2.43 diopters (D) in the single surgeon group and -5.36 +/- 2.34 D in the multiple surgeon group. Follow-up of 6 months was available on 109 eyes (83%) in the single surgeon group and 289 eyes (68%) in the multiple surgeon group. At 6 months, the average residual refractive error was +/- 0.15 +/- 1.13 D in the single-surgeon group and +0.21 +/- 1.15 D in the multiple surgeon group. This difference was not statistically significant (p = 0.68). Correction within 1 D of attempted correction was obtained in 76 eyes (70%) in the single surgeon group and in 223 eyes (77%) in the multiple surgeon group. Uncorrected visual acuity of 20/40 or better was achieved in 89 eyes (82%) in the single surgeon group and 253 eyes (88%) in the multiple surgeon group. CONCLUSION: Refractive and visual acuity outcomes after photorefractive keratectomy are influenced minimally by the refractive surgical experience of the surgeon.

Corneoscleral melt after pterygium surgery using a single intraoperative application of mitomycin-C.

A 59-year-old man underwent pterygium excision with intraoperative application of 0.2 mg/ml (0.02%) mitomycin-C placed on the scleral bed for 3 min. A sliding conjunctival flap was used to cover the exposed limbus and sclera. Five weeks after the original surgery, the patient had mild trauma and noted decreased vision. At that time, it was noted that he had a corneoscleral melt with perforation. The patient was managed with a lamellar transplant in this area. Intraoperative single-dose application of topical mitomycin-C can be associated with serious complications. This case occurred despite the fact that this patient received the lowest dose used in a series of 25 eyes using the same technique without any other complications. Although topical mitomycin-C is effective as an adjunct to pterygium surgery and may reduce recurrence, the safety and efficacy of various concentrations and dosing schedules need further definition.

Excimer laser ablation rate and corneal hydration.

During excimer laser photorefractive keratectomy, dehydration of the cornea begins as soon as the epithelium is removed. Corneal hydration might affect the excimer laser ablation rate, which could affect the accuracy of correction. We studied the effect of corneal hydration on the excimer laser ablation rate in bovine eyes. To control hydration, bovine corneoscleral rims were equilibrated in dextran solutions of varying concentrations. One button trephined from each rim underwent laser ablation. Hydrated tissue ablation rates (amount of collagen, ground substance, and water removed per pulse) and dry component ablation rates (amount of collagen and ground substance removed per pulse) were calculated from mass removed. The hydrated tissue ablation rate at physiologic hydration was 0.40 micron/pulse. As corneal hydration increased, the hydrated tissue ablation rate increased by 5.6 micrograms/cm2/pulse per increase in unit corneal hydration (simple linear regression analysis, P = .0001). The dry component ablation rate decreased linearly by 0.82 microgram/cm2/pulse per unit increase in corneal hydration (simple linear regression analysis, P = .0001). Both clinical data and theoretical arguments imply that dry component ablation rate determines refractive outcome after photorefractive keratectomy. Since the dry component ablation rate increases as the cornea dries, significant dehydration of the cornea before ablation might lead to relative overcorrections of myopia. Surgeons should use a technique that minimizes changes in hydration to maximize the predictability of excimer laser photorefractive keratectomy.

Eye disease among ambulatory Jewish senior citizens in California.

Knowledge of the epidemiology of eye disease among the elderly becomes increasingly important as our population ages. Leading causes of blindness in the elderly include age-related macular degeneration, open-angle glaucoma and cataract. Few studies have examined the prevalence of these blinding eye diseases among senior citizens. A retrospective review of vision screening examinations from 429 patients seen at the UCLA Mobile Eye Clinic in visits to a Jewish senior citizens' center was performed to examine the distribution of best recorded visual acuity and prevalence of eye disease in a group of ambulatory Jewish senior citizens. Best recorded visual acuity was > or = 20/40 in the better eye for 83.9% of the patients. The prevalence of age-related macular degeneration was 20.7%, and increased with increasing age (p < .00005). The prevalence of open-angle glaucoma was 6.3%. The prevalence of senile cataract was 59.0% and increased with increasing age (p < .00005). Despite the limitations imposed by a retrospective review of charts, our study provides an indication of the prevalence of blinding eye disease and distribution of visual acuity among ambulatory Jewish senior citizens in southern California. Except for the high prevalence of senile cataract, the prevalence data derived from this study are similar to other epidemiologic studies of eye disease in the elderly.

Acanthamoeba sclerokeratitis.

We treated a healthy soft contact lens wearer who developed Acanthamoeba sclerokeratitis in the left eye. The patient had severe pain and ring-shaped subepithelial infiltrates. The keratitis progressed and scleral nodules developed despite aggressive treatment with topical clotrimazole, dibromopropamidine isethionate, and corticosteroids. Corneal transplantation and cryotherapy were performed. The corneal button demonstrated Acanthamoeba cysts. Cultures of biopsy specimens taken from two different scleral nodules at two separate times were positive for Acanthamoeba. The disease progressed despite a second corneal graft and the addition of polyhexamethylene biguanide eyedrops. Enucleation of the left eye was required. Histopathologic examination of the specimen documented an Acanthamoeba cyst associated with a granulomatous inflammatory response deep in the sclera. Acanthamoeba scleritis may be associated with a poor prognosis, even with intensive medical and surgical treatment.

Wartime amputations.

The development of amputation surgery has closely paralleled progress in combat casualty care. Since the Civil War, care at hospitals close to the front lines has been improved by advances in both medical care (safer anesthesia, antibiotics, and fluid resuscitation) and medical field service (field hospitals and evacuation of the wounded). This progress has helped reduce the morbidity and mortality of all combat casualties. Surgical management of patients with amputations has evolved to the open circular technique, which is currently recommended for initial management of battlefield casualties. Because residents are not routinely taught this technique, military surgeons have been forced to relearn it during every conflict since World War II. This paper outlines the indications, techniques, and special postoperative care of amputees from the Civil War through Vietnam.

Iliac crest bone graft. Osteotome versus saw.

The strength of saw-harvested vs. osteotome-harvested Smith-Robinson iliac crest grafts from five fresh frozen cadavers was compared. Matched pairs of grafts were harvested, one with a saw and the other with an osteotome from equivalent locations on the two iliac crests of each pelvis. Grafts were tested to failure in axial compression, and load-displacement curves were recorded for each test. Yield load and displacement, ultimate load, and stiffness were calculated, and statistical analysis was performed with the Student t test and three-way analysis of variance. Evaluation of the 66 pairs of grafts revealed that saw-harvested grafts were consistently stronger than were matched grafts harvested with an osteotome. The middle third of the iliac crest produced significantly stronger grafts, and those harvested from younger donors were significantly stronger than those obtained from older donors. Of even greater clinical relevance, saw-harvested grafts were stiffer than osteotome-harvested grafts. Based on these findings, it is recommended that iliac crest grafts harvested for spine fusion be obtained with an oscillating saw rather than with an osteotome.

Theodor Kocher and the Scientific Foundation of Wound Ballistics.

The systemic and rational approach used by Kocher, coupled with his interest in research of wound ballistics for more than 40 years, resulted in a clear elucidation of the principles that form the basic scientific foundation of modern wound ballistics. The validity of his work has been proved repeatedly on the battlefields of the world for more than a century. Presently, more than ever before, the sound scientific precepts revealed by Kocher are essential to keep technologic investigation within the framework of good judgment.

Armored vehicle crew casualties.

The use of armored vehicles since the First World War has created a subset of casualties with a different epidemiology than infantry soldier casualties. The preponderance of armored fighting vehicles (AFVs) in the world's armies make their use in a future war likely. The purpose of this paper is to review the nature of possible injuries to crewmembers of these vehicles by historical and experimental data. Injuries to armored vehicle crewmembers are characterized by a large number of burn casualties, a larger percentage of fractures and traumatic amputations with extremity wounds, and a higher mortality when compared with infantry footsoldier combat casualty statistics.

Improved comfort and patient acceptance in a novel transdermal nitroglycerin delivery system.

Sixty-three angina patients were recruited to participate in a two-week, randomized, open-label, crossover, multicenter trial to compare patient acceptance of two transdermal nitroglycerin delivery systems, Minitran and Transderm-Nitro (TDN). Patients were enrolled if they had stable angina and had been on a stabilized dose (5, 10, or 15 mg/24 hr) of Nitro-Dur II (ND II) for at least one month before entering the study. Patients with a bias against TDN or with any of the contraindications for transdermal nitroglycerin therapy were excluded. During the two consecutive one-week treatment periods, the patients received their prestudy dose regimen of Minitran and TDN in random order. Patients completed daily diaries, weekly questionnaires, and poststudy patient preference evaluation forms. Of the 63 patients who completed the study, 70% preferred Minitran overall (P less than or equal to 0.001), 24% preferred TDN, and 6% had no overall preference.